Provider Demographics
NPI:1487084422
Name:BLACKBURN, STEVE L (MHA, MPAS, PA-C)
Entity type:Individual
Prefix:MR
First Name:STEVE
Middle Name:L
Last Name:BLACKBURN
Suffix:
Gender:M
Credentials:MHA, MPAS, PA-C
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Mailing Address - Street 1:W180N8085 TOWN HALL RD
Mailing Address - Street 2:HEART & VASCULAR CENTER CLINIC
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-3518
Mailing Address - Country:US
Mailing Address - Phone:262-532-1300
Mailing Address - Fax:262-532-1340
Practice Address - Street 1:W180N8085 TOWN HALL RD
Practice Address - Street 2:HEART & VASCULAR CENTER CLINIC
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-3518
Practice Address - Country:US
Practice Address - Phone:262-532-1300
Practice Address - Fax:262-532-1340
Is Sole Proprietor?:No
Enumeration Date:2013-11-12
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3230-023363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1487084422Medicaid